How to manage acidemia potentially caused by Crest (sodium fluoride)?

From the Guidelines

To manage acidemia potentially caused by Crest (sodium fluoride), immediate medical attention is required, and sodium bicarbonate should not be used to improve hemodynamics or reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15, as recommended by the Surviving Sepsis Campaign guidelines 1. The treatment of acidemia caused by sodium fluoride ingestion involves several key steps:

• Stop using the product and call poison control at 1-800-222-1222 or seek emergency care.
• Administration of calcium gluconate or calcium chloride to bind with fluoride ions, preventing further absorption and reducing toxicity.
• Intravenous fluids may be given to correct fluid imbalances and support kidney function in eliminating fluoride.
• Cardiac monitoring is essential as fluoride toxicity can cause cardiac arrhythmias.
• Magnesium sulfate might be given to address potential electrolyte imbalances. The severity of acidemia from sodium fluoride ingestion stems from fluoride's ability to bind with calcium and magnesium, creating metabolic disturbances and inhibiting essential enzymes in cellular metabolism, as noted in the guidelines 1. Most cases of fluoride exposure from toothpaste are mild and resolve with supportive care, but significant ingestion requires prompt medical intervention to prevent serious complications, and the use of sodium bicarbonate is not recommended for the treatment of hypoperfusion-induced lactic acidemia with pH ≥ 7.15, as stated in the guidelines 1. Key considerations in the management of acidemia include:
• The patient's pH level, as sodium bicarbonate is not recommended for patients with pH ≥ 7.15 1.
• The presence of other diseases, such as mesenteric ischemia, which may affect the treatment approach 1.
• The potential for sodium and fluid overload, increase in lactate and Paco2, and decrease in serum ionized calcium associated with bicarbonate administration, as noted in the guidelines 1.

From the FDA Drug Label

Indications: Relieves: acid indigestion heartburn sour stomach upset stomach associated with these symptoms The FDA drug label does not answer the question.

From the Research

Management of Acidemia

• Acidemia can be a serious condition that requires prompt treatment, and managing it potentially caused by Crest (sodium fluoride) involves understanding the underlying causes and appropriate interventions.
• The use of sodium bicarbonate in treating metabolic acidosis has been debated, with some studies suggesting its effectiveness in certain cases 2, 3.
• However, other studies have raised concerns about the potential negative effects of sodium bicarbonate, such as paradoxical intracellular acidosis 3 and lack of evidence supporting its use in lactic acidosis 4.

Treatment Options

• Dichloroacetate has been shown to be a safe and effective adjunct in treating patients with lactic acidosis, although the ultimate prognosis may depend on the underlying disease 5.
• Supportive therapy and withdrawal of offending drugs can also be effective in resolving acidosis, as seen in a case of pyroglutamic acidaemia 6.
• It is essential to identify and address the underlying cause of acidemia, ensuring adequate oxygen delivery to tissues and reducing oxygen demand through sedation and mechanical ventilation 4.

Considerations

• The decision to use sodium bicarbonate should be made on a case-by-case basis, considering the severity of acidemia and the potential risks and benefits 2, 4.
• Monitoring intracellular pH and adjusting treatment accordingly may be necessary to avoid paradoxical intracellular acidosis 3.